Frequently Asked Questions (FAQ) About Tracheotomy and Swallowing

This FAQ was developed by affiliates of ASHA's Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia): Debra Suiter (coordinator), Susan Brady, Karen Dikeman, Amy Mandaville, Donna Scarborough, and Steven Leder. This FAQ does not represent an official position or policy of ASHA.

What patient factors can influence the impact of tracheotomy on swallowing function?

Aspiration is more likely due to the medical status of the individual patient than to the presence of the tracheotomy tube itself. Patients with a critical illness that requires tracheotomy and mechanical ventilation are at higher risk for aspiration. Patient factors include

trauma

severe pulmonary disease

advanced age and reduced functional reserve due to sarcopenia

altered mental status

use of medications used to treat the critically ill

What is the purpose of the inflated tracheotomy cuff?

The main purpose of an inflated tracheotomy tube cuff is to maintain the air delivered from the ventilator to a patient's lungs. The inflated cuff, an internal balloon that surrounds the outer cannula or body of the tracheotomy tube, fills the tracheal space around the tube and prevents breath from escaping through the upper airway. The inflated cuff prevents leakage of air, thereby creating a closed loop between the ventilator and patient and ensuring a consistent delivery of air. However, during periods of cuff inflation, air is not available for phonation or swallowing. The impact on voice, creating aphonia, is immediately evident.

What is the impact of cuff inflation, versus cuff deflation, on swallowing?

The tracheotomy cuff provides little protection against penetration or aspiration. Unless it is removed by suctioning or coughing, aspirated material that reaches the cuff will "leak" around the sides of the tube and into the trachea and bronchial airways. Further, residue on top of cuff can be aspirated after deflation.

Deflating the cuff makes it possible for the patient to generate airflow to cough via the upper airway. When the cuff is inflated, the cough is directed out through the tracheotomy tube. Some experts consider cuff deflation an essential procedure in a thorough clinical or instrumental swallowing evaluation. However, the issue of cuff inflation versus cuff deflation is only one factor in the management of dysphagia for these patients.

What are the complications of long-term cuff inflation?

The friction created around the cuff site—or "rubbing" on the tracheal walls—has been linked to

chronic irritation and erosion, leading to the formation of a fistula (hole in the tracheal wall)

tracheomalacia (softening of the tracheal tissue) and tracheal stenosis (narrowing of the trachea)

tracheoesophageal fistula, which may result when an overinflated malpositioned tracheotomy tube cuff is present for long periods, especially in the presence of a nasogastric tube

ulceration, necrosis, and scarring that may create stenosis and typically require some type of surgical repair

Instances of both fistulas and stenosis have been greatly reduced by the use of high volume, low pressure cuffs typically manufactured today.

What is the benefit of cuff deflation at assessment?

Cuff deflation allows the clinician to assess airway competence and airway protection abilities via vocal quality at baseline and during clinical or instrumental assessments. Strategies (e.g., throat clearing and intermittent coughing/clearing) can also be trialed.

What effect does occlusion of the tracheotomy tube have on swallowing?

Occluding the hub of a tracheotomy tube (with a fully deflated cuff) may be accomplished via

a gloved finger

a one-way speaking valve

a tracheotomy tube cap or cork

It has been suggested that tracheal occlusion will improve swallowing, because of its ability to re-establish subglottal airway pressure and restore upper airway flow. Occluding the tracheotomy tube has been associated with improved management and reduced levels of accumulated oropharyngeal secretions. However, large amounts of accumulated pharyngeal secretions can suggest poor airway protection. Because several factors may be associated with swallowing dysfunction in patients with tracheotomy, it is recommended that the clinician perform the evaluation under a variety of occlusion conditions to determine whether tracheotomy tube occlusion will improve the patient's swallow function.

How effective is the "blue dye" test in detecting aspiration in patients with a tracheotomy tube?

Results of the "blue dye" test have been shown to be inconsistent when compared with findings of both videofluoroscopic and FEES evaluations. Therefore, the "blue dye" test (including colored foods) may be best viewed as a screening tool.

The availability of blue dye is limited due to an
FDA Advisory in 2003.

Are there risks to using compensatory strategies/maneuvers in patients with a tracheotomy?

Some risks may be associated with using certain strategies or postures with this population. For example,

A chin tuck or head turn posture may create a risk of dislodging the tracheotomy tube.

Is it in the scope of practice for speech-language pathologists to change tracheotomy tubes or suction patients?

ASHA's Code of Ethics stipulates that clinicians must be competent in any area in which they practice. ASHA's Scope of Practice in Speech-Language Pathology is quite broad and does not address specific procedures; however, procedures should be related to the assessment and treatment of patients with communication or swallowing disorders. Individual facilities usually have specific processes for "credentialing" staff and will provide training and support for teaching speech-language pathologists to suction. Speech-language pathologists should also consider potential liability issues of related activities, such as changing or capping tracheotomy tubes, as these may be considered procedures that should be done by medical professionals.

State licensure laws vary; for example,
Maryland has determined that tracheal suctioning is within the scope of practice for speech-language pathologists. Other states may or may not have such specific guidance.

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The American Speech-Language-Hearing Association (ASHA) is the national professional, scientific, and credentialing association for 191,500 members and affiliates who are audiologists; speech-language pathologists; speech, language, and hearing scientists; audiology and speech-language pathology support personnel; and students.